Infants (0-12 months) Background

The dynamic growth and development experienced in infancy is the most
rapid of any age. The progression in feeding skills (Exhibit
3.1) marks important developmental milestones that support rapid changes
in food habits and nutrient intakes. The frequency of dietary assessment
during infancy is an important methodological issue in longitudinal studies,
as is the selection of a method validated for the developmental stage
of the infant and for the specific research questions.

Self-feeding with hands emerges
Munching and biting emerges
Indicates hunger and fullness clearly
Prefers bottle, but can hold open cup with little loss

10-12 months

Likes self-feeding with hands
Spoon feeding emerges
Drinks from an open cup as well as bottle
Enjoys chopped or easily chewed food or foods with lumps
Sitting position for eating
Enjoys table foods even if some baby foods still used

Assessing breastfeeding behaviors, breast milk intake, and milk composition
present additional methodologic issues to address, especially because
more than two-thirds of mothers currently initiate breastfeeding and about
a third of infants are still consuming breast milk at 6 months of age
(25;29;70). The benefits of breastfeeding to both the mother and infant
are well documented, and it is encouraging that U.S. breastfeeding rates
are projected to increase by at least 2 percent per year by 2010 (29).
However, the considerable variation in the content of breast milk between
women, and within the same woman from day to day, from feed to feed, and
during a single lactation (31;32) all make the measurement of breast milk
composition and infant intake challenging. Sources of variation include
the stage of lactation, parity, maternal body composition, nutritional
status, time of day, and within-feed timing of breast milk sample collections
(71). Feeding frequency and duration of feeds also differs among women;
frequent feedings of up to 10 to 12 feedings a day are not unusual (33),
making application of current dietary assessment methods difficult. The
lack of consistent definition of breastfeeding behaviors (e.g., exclusive,
partial) in the dietary assessment literature (30) also has made comparisons
among studies difficult.

Assessing formula intake is not without methodologic challenges. Data
on formula preparation methods must be collected. The amount of formula
consumed versus the amount offered at a feed must be quantified. In both
breast and bottle feeding, the amount of infant regurgitation (spitting
up) or drooling during or after feeding may be an important issue in some
infants. A further challenge is that many infants receive both breast
milk and formula each day. As the infant begins consuming complementary
foods, collecting portion size information on the small quantities consumed
is difficult. Although not recommended, many infants receive complementary
foods such as cereal mixed in a bottle with formula, further complicating
accurate assessment of intake.

Another issue is identifying and selecting surrogate reporters of the
infant's intake. About one-third of employed mothers with children less
than three years of age return to work within 3 months after childbirth,
and about two-thirds within 6 months of childbirth (72;73). This requires
information from all of the different adults who care for the infant.

Validation of Dietary Assessment Methods in Infant Populations

Collection of a Breast Milk Sample

Human milk samples are used to investigate the nutrient content of the
milk and to assess level of exposure of infant populations to certain
environmental chemicals. The lack of standardized methods for collecting
breast milk samples has hampered evaluation of the literature and made
valid comparisons between studies difficult (71).
Although the specific protocol for collecting human milk is dependent
on the research question, the recommendations in Exhibit 3.2 represent
current consensus on guidelines for collecting and storing human milk.

Exhibit 3.2. Guidelines for Collection and Storage
of Human Milk:
Recommendations from the 2002 Technical Workshop on Human Milk Surveillance
and Research on Environmental Chemicals in the United States (71)

Milk sampling should neither be an undue burden to the mother
nor compromise the nutritional status of the infant.

Standardize study protocols for the time of the day that all subjects will
collect milk; the time elapsed since the previous feeding on the breast to
be pumped should be at least 2 hr.

Provide standardized collection and storage containers composed of natural
material that does not influence the measurement of the chemical to be analyzed.

Instruct mothers to use an electric breast pump to express breast milk;
a trained individual may need to deliver, demonstrate, and pick up the electric
pump.

For each collection, the mother should:
1. Wash the breast with a mild contaminant free soap and rinse the breast
with distilled water.
2. Apply the breast pump to the breast and express milk until milk flow
declines to a drip; pumping may be done at the same time the infant is nursing
from the other breast.
3. Add collected milk to the storage container kept in the home freezer until
the total volume needed for analysis is collected.

Transport milk to the laboratory in a cooler with dry ice to keep samples
frozen; clearly mark the transport cooler with a biohazard label marked "human
milk samples.

Test Weighing

The most validation work in this age group has focused on assessing infant
milk intake by test weighing. This method involves weighing the infant
immediately before and after each feeding without change of clothing or
diapers and taking the gain in weight of the infant (in grams) to be the
net milk intake (in milliliters). An alternative approach in breastfed
infants involves weighing the mother before and after each feeding (75).
The introduction of electronic balances, which can integrate moderate
movements and record these weights, has improved the accuracy and precision
of measuring the weight of the infants (76;77).

Scanlon et al. published a thorough review of test weighing validation
studies published through 2000 (78).
Additional work in this area was not identified. Test weighing of formula-fed
preterm and full-term healthy infants (Table
3.1) in the hospital by nursing staff using an electronic scale showed
agreement between test weighing of the infant and the direct measurement
of formula within 1 percent (79).
In home settings including five to 10 mother-infant pairs, infant test
weighing and formula measurements by the mother underestimated intake
by 7 to 10 percent using a mechanical scale (80)
and overestimated intake by 7 to 11 percent using an electronic scale
(75).

Test weighing validation studies in breastfed infants have focused on
modifications of procedures to reduce the maternal burden and disruptions
of feeding. Results of three studies (31;81;82) examining whether breast
milk intake could be estimated from the product of test weights for one
or two feeds in a 24-hour period found the highest correlations between
intakes estimated with 24-hour test weighing and estimates calculated
from two consecutive test weights in the mid 24-hour period. Differences
in mean intake estimates ranged from a 0.6% overestimation among infants
4 weeks of age to an 6% underestimation among infants 12 weeks of age
(31). Meier validated the accuracy of home test weighing by mothers using
the Baby Weigh electronic scale in a population of pre-term breastfeeding
infants (76).

The test weighing method has several obvious limitations for a large-scale
longitudinal study. Test weighing is tedious and requires careful training
and supervision of mothers with some degree of technical sophistication
who can operate an expensive electronic balance in the home (82). Test
weighing also interrupts usual feeding routines. When milk intakes of
breastfed infants are compared to those of formula-fed infants, both
groups of infants should be test weighed (80). No studies have validated
test weighing with combined feeding regimens (formula and breastfeeding).

Infant milk intake indirectly estimated from measurements of infant total
energy expenditure (TEE) with the DLW method has been validated in
small groups of formula-fed (83-86)
and breastfed infants (83;87;88)
in hospital and home settings (Table
3.1). The method involves carefully (avoiding loss from spitting up)
administering a DLW dose to the infant and collecting samples of urine
or saliva at baseline and over the subsequent 5 to 15 days. To increase
accuracy of energy expenditure measurements, water from supplemental foods
or fluids other than milk must be measured and adjusted for, as well as
environmental water influx, insensible water losses, change in energy
stores during the study period (change in weight), and the macronutrient
content of the diet. The method has been refined over time and later studies,
correcting for environmental water influx and insensible water loss, found
close agreement (1 to 2% in formula studies and 2 to 5% in lactation studies)
between energy intake estimated by the DLW method and direct measurement
of formula or test weighing of breastfed infants.

The DLW Method has a number of advantages because it is non-invasive
and requires no special equipment. The method does not interrupt infant
feeding patterns, it allows for greater mobility of the mother-infant
pair, it is unaffected by daily variations in intake or frequent feedings,
and is practical under field conditions (87).
However, the availability and cost of the isotopes, the need for sophisticated
laboratory analysis, and the care required to administer the DLW dose,
limit its use in large samples of infants.

Direct Observation

Direct observation involves estimating the volume of breast or formula
milk consumed by visually assessing the infant during feeding. Studies
by Meier on preterm infants and/or high-risk infants found low correlations
(0.48 to 0.79) and large and random errors between direct observation
and test weighing when observations were performed by either mothers,
nurses, or lactation consultants (89). Mothers and investigators gave
comparable, yet inaccurate, estimates of infant milk intake over a single
feed (r = 0.91) demonstrating that direct observation cannot be substituted
for test weighing if an accurate measure of infant intake is necessary.

Other Methods

Only six studies examining the validity of other dietary assessment methods
in older infant populations were identified (Table
3.1). A 2001 study compared energy intake measured by a 5-day estimated
Food
Record with a 5-day weighed Food Record and the DLW method in a cross-over
study design in 6- to 12-month old infants (90).
Both weighed and estimated food records overestimated DLW measurement
of energy expenditure by 7%. A diet history method was compared with a
weighed food record in two studies (91-93);
although the diet history methods were not comparable, both overestimated
intake measured with a 3- or 4-day weighed food record. The use of the
Portable Electronic Tape Recording Automated (PETRA) scale in the home
was found to be difficult in a British study of children from low-literacy
Asian immigrant households because the equipment malfunctioned or was damaged
in the home and it required intensive participant instruction and monitoring
(92).

Though not validation studies, Stuff et al. (94)
and Black et al. (95)
each studied the day-to-day variation in energy intake of breastfed infants
through rigorous tests weighing (Table
3.4). In both studies, the range of pooled within-subject coefficient
of variation was wide and increased as the infant aged and more complementary
foods were introduced. Black's study includes measurements through 18
months and concluded the number of days of food records needed for breastfed
infants is 4 days and for toddlers is 7 days (95).

Two studies examined the validity of the 24HR (24-Hour
Recall) method. In one study a 24HR collected 24 hours after collection
of a duplicate diet by the parent resulted in a significant overestimation
of energy and other nutrients (96).
A study validating telephone 24HR interviews with face-to-face 24HR in
telephone and non-telephone households in the lower Mississippi Delta
Region found no significant differences in mean energy intakes, but the
results for the 32 infants included in the study of 409 participants were
not analyzed separately (97).

Only one FFQ validation study was found. Marshall (98)
compared parental reports of beverage intake of infants at 6 and 12 months
on a mailed beverage FFQ (Food
Frequency Questionnaire) with a 3-day FR (Food
Record) of all foods and beverages consumed. This FR was completed
the week after completing the FFQ. Correlations with types of milk consumed
ranged from 0.83 to 0.99 while correlations between methods for measurements
of water, juice/drinks, or soft drinks were lower.

In the early 1980s, a study comparing an interview that included short
questions on breastfeeding practices with the infant's medical record
found mothers overestimated reporting of length of previous breastfeeding
when questioned at 12 months (99).